Commentary on the human elements of medical care. In particular, the focus is on the experience of being a patient, the experience of being a physician or other health care professional, and the resultant impact on the relationship between patient and physician. These are the key factors on the quality of health care for the patient and on the physician's satisfaction and sense of meaningfulness in their work.

Tuesday, November 3, 2015

I think that there are at least two ‘belief orthodoxies’ in the Balint community: “Participation in Balint groups teaches empathy,” and “Participation in Balint groups combats (if not prevents) burnout.” It is not surprising, then that so many efforts at documenting (researching) the impact of Balint rely on measures of these two ‘outcomes’ - Jefferson Empathy Scale and the Maslach Burnout Inventory. However, as I have written previously, most of these research efforts have only modestly positive results. While it is possible that in fact these are two of the outcomes that Balint group participants may experience, I believe that these two ‘outcomes’ are indirect or second or third tier effects, and that the Balint group process and experience is much more complex and multi-level. One framework I have used to explore this complexity is a ‘Realistic' research approach which seeks to identify the varying contexts under which an intervention or mechanism of action has its impact and produces some outcome (the C-M-O configuration).

The implication of “Participation in Balint groups teaches empathy” is that empathy is lacking among participants of Balint groups. Very often, the cases that are brought to the Balint group are cases in which the physician has difficulty connecting with the patient or a case in which the physician experiences some interference in his/her developing a full understanding of his/her patient’s challenges. I would like to suggest that these physicians are not lacking empathy at all; however, they have become distracted in the course of providing medical care. (Thanks to Clive Brock for this idea of distraction!)

What could possibly be distracting a physician who is meeting with a patient seeking their help? In order to get a better sense of possible or likely distractions, one need only look at a typical day of a physician. They are scheduled to see patients every 15-20 minutes and very often patients have multiple concerns that need to be evaluated. There is probably a long list of return phone calls and prescription refill requests to respond to, and the doctor has to record everything he or she does in their electronic health record. Add to this already full day complications from a patient’s chronic illnesses, interference from insurance regulations that limit payment for preferred treatment strategies, concerns about patients who are seeking narcotics for their intractable pain, delivery of worrisome lab results from patients he saw yesterday, and on and on.

Empathy has not disappeared! Rather, empathy is hiding! Or possibly empathy is hidden - hidden behind defense mechanisms, hidden behind prejudices about narcotics (or other pet peeves), hidden behind the need to see and fix patients quickly, hidden behind false reassurances, hidden behind medical jargon and procedures and tests. On many days, many doctors feel like they are under siege. When any of us feels this way, we hide - we try to disappear- we need time to recoup -

Nature to the Rescue:

A couple of days ago, after several miserable days of rainy, cloud covered skies, my wife and I were taking a walk in the park, and we were enjoying the emerging sun shine as the cloud covered skies finally began to clear. My wife commented that “It was great that the sun has finally come out.” And I thought to myself and then said out loud “The sun hasn’t just come out! It has always been there - it’s the clouds that have moved, no longer blocking the sun!”

And it hit me right away! I have been thinking and doing some writing about the idea that physicians do not lose their empathy. I would like to make the case that Balint groups do not need to teach empathy! In fact, like the sun covered by clouds, empathy is always there. Physicians who are typically empathic did not lose their empathy. However, it is likely that any one of a number of things have intervened, interfered or otherwise distracted them from a more generous acceptance of their patient’s plight. So now, the question becomes what is the nature of the interferences or distractions that professionals experience in their efforts to deliver medical care?

When we are thinking about the sun, the interferences are cirrus, cumulus or stratus clouds, or a low pressure front or a nor’easter. Wouldn’t it be interesting to have categories of interferences between doctor and patient? What would the implications be for research? Clive Brock has published a paper about the roles doctors take on and ways they interfere with the doctor's goals. It's nice to play the white knight, but there are limits to his ability to rescue! Maybe Balint group participation teaches emotional intelligence - albeit, indirectly - but E.I. just the same. Could I possibly give up my fantasy of being a white knight? I’ll take this on as a future post! Maybe readers might also make their suggestions …